NU 428 Women's Oncology

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1

What are the characteristics of breast cancer?

ž2nd most common female malignancy in American Women

2nd only to lung CA in actual death rates

Slight decrease in previous years

Doctors only give hormone replacement therapy temporarily to alleviate menopausal symptoms. The less, the better when it comes to risk for cancer.

2

What are the ACS recommendations for women regarding cancer screening?

žWomen 20 – 39 yrs: BSE Monthly & Clinical breast exam /q 3 yrs

ž> 40 yrs: BSE monthly, Clinical breast exam & Mammography yearly

žRelative distribution of breast tumors

  • 18% behind nipple & areola
  • 15% upper medial aspect
  • 6% lower medial aspect
  • 50% upper outer quadrant
  • 11% lower outer quadrant
3

What are the risk factors for breast cancer?

žModifiable:

Cumulative

Sex hormones

  • May act as tumor promoters.
  • Estrogen & progesterone are examples.
  • HRT postmenopausal
  • Lifetime OCP use

Sedentary lifestyle

Dietary fat intake

Obesity: Wt gain and obesity after menopause is more dangerous.

Alcohol intake

Smoking

1st full term pregnancy after age 30

Nulliparity: Pregnancy is protective against breast cancer. More pregnancies, less risk of cancer. Makes hormone production less.

žNon-Modifiable Risk Factors:

Environmental factors

  • Chemical
  • Pesticides
  • Radiation (i.e. teens): X-ray radiation before or during teenage years is a huge risk factor

Age > 60

Family HX

  • 1st degree relative is —largest lone risk factor

BRCA 1 & 2 genes

  • —5-10% of all inhered breast cancers.
  • —Increases lifetime risk 40-80%.

Early menarche (<12 y/o) and late menopause (>55 yo)

Benign breast disease – fibrocystic dx. Women with this disease sometimes miss tumors on palpation bc they don't know the difference btwn a cyst and a tumor mass.

4

What is the pathophysiology behind breast cancer?

žDevelops when there are alterations in the DNA of breast cells. Particularly epithelial cells of the: Ductal (milk passages) and lobular (milk producing) tissue

žMay be invasive or in situ (At the site without spread)

žFactors affecting prognosis:

  • Tumor Size
  • Axillary node involvement
  • Tumor differentiation
  • Estrogen & progesterone receptor status
  • Human epidermal growth factor receptor 2 status. Helps regulate cell growth. Over-expressed in breast cancer pts
5

What are two types of noninvasive breast cancer?

žDuctal Carcinoma in situ (DCIS)

  • Tx - mastectomy.
  • Unilateral.
  • Likely to progress to invasive Ca if left untreated.

žLobular Carcinoma in situ (LCIS)

  • Carries a risk of invasive BR CA - not a true premalignant lesion.
  • Watch it closely
  • No treatment is recommended at the beginning.
  • Tx- mastectomy
  • Slow-growing
6

What are the characteristics of Paget's Disease?

Persistent lesion of the nipple & areola

With or without mass.

žTumor originates in the nipple

žSX = itching, burning, bloody nipple d/c, superficial ulceration

žDX = confirmation by patho exam of erosion

žTX = lumpectomy or mastectomy

žPrognosis = good if CA confined to nipple

7

What are the characteristics of inflammatory breast cancer?

žMost malignant form of all BR CAs

žRare

žAggressive & fast growing

žSX: Skin looks red, feels warm, thickened, appears like orange peel

žBreast may develop ridges & small bumps resembling hives

žTX:

  • Radiation
  • Chemotherapy
  • Hormone therapy
  • Biologic therapy
  • Surgery

žMetastases occurs early & widely: tentacle like projections emanating from tumor.

8

What are the clinical manifestations of breast cancer?

žUsually single lump or thickening on mammogram

~ ½ - upper outer quadrant

Lump is usually:

  • Hard
  • Irregular in shape
  • Poorly delineated
  • Nonmobile
  • Nontender

žMay have nipple discharge

  • Unilateral
  • Clear
  • Bloody

žMay have orange peel look

žDimpling may occur

žUnusual nipple retraction

ž

9

What are some complications of breast cancer?

1.Recurrence (local, regional, distal)- Majority 3-4 yrs after initial treatment. Normally, see recurrence at the exact spot of tissue where tumor originated from.

2.Metastasis

  • Colonies of cancerous breast cells in distant parts of the body.
  • Occurs primarily thru lymphatic channels of the axillae.
  • Can occur even /w node – disease.
10

What are some diagnostic studies used for breast cancer?

žAxillary Lymph Node Dissection – (removes all detectable lymph nodes)

  • Used to determine if the cancer has spread to the axillae on involved side.

žLymphatic Mapping and Sentinel lymph node biopsy

  • To identify lymph nodes draining from the tumor site.
  • Sentinel node is the largest & closest to the tumor.
  • Blue dye injected into tumor site - surgeon makes incision & takes out blue-stained sentinel node.
  • If sentinel node is + then ALND is usually done.

žTumor size

  • Larger = more risk of relapse

žEstrogen-progesterone receptor status- (Receptor onto which CA cells can attach)

  • Receptor positive = better prognosis/less relapse
  • Receptor negative = more risk for recurrences

žCell proliferation indices

  • Indirectly measures rate of tumor cell proliferation.

žGenetic marker = HER -2

  • Over-expression - associated /w poor prognosis in br ca.

žTriple negative BC

  • Negative for estrogen, progesterone, & HER receptors.
  • Poorer prognosis and more aggressive tumors.
11

What are treatments for breast cancer?

žTreatments are available based on the TNM system

žBased on: Tumor size (T), Nodal involvement (N), and Presence of metastasis (M)

*Depending on these factors, this results in staging. Stage of disease (I – IV)

žMost common options used today:

Breast Conservation Surgery

  • I.e. lumpectomy.
  • Removes entire tumor & margin of normal tissue.
  • Usually followed /w radiation – sometimes with chemo too.
  • Advantages: —Breast & nipple preserved.
  • Disadvantages: Cost, —radiation effects

Modified Radical Mastectomy

  • Removal of breast & axillary lymph nodes.
  • Preserves pectoralis major muscle.
  • Used if tumor too large to get good margins of surrounding tissue.
  • Reconstruction surgery may be performed immediately if client desires.

žLymph Node Dissection:

  • Axillary Node Dissection: Provides prognosis & helps determine further treatment.
  • Sentinel Lymph Node Biopsy: Reduces unnecessary lymph node dissection.
12

What post-operative patient teaching should a nurse include in the plan of care for a breast cancer patient?

Follow up for both procedures for rest of life @ regular intervals: q 3-6 months for 5 yrs, annually thereafter.

Teach:

  • —SBE /q month
  • —Self chest wall exams
  • —Yearly mammograms (both breasts and surgical site)
  • —Should still have breast imaging (mammogram/U/S q 6 mos-1 yr)

ž

13

What are some long-term breast surgery effects?

žLymphedema – They lose their ability to drain lymph fluid properly.

SX:

  • —Heaviness
  • —Pain
  • —Parasthesia
  • —Fever and painful rash
  • —Cellulitis

Nsg measures to control lymphedema:

  • —Frequent elevation of arm
  • —Exercises
  • —Regular use of custom- fitted pressure sleeve
  • CAUTION= NO B/P; venipunctures, vaccines, IVs in affected arm

žPostmastectomy Pain Syndrome – like phantom pain

S/S:

  • Chest & arm pain
  • Tingling
  • Numbness
  • Unbearable itching

Tx:

  • NSAIDs
  • Antidepressants
  • Topical lidocaine patches
  • EMLA cream
  • Neurontin
14

What are the different types of breast reconstruction available?

ž1) Flap reconstruction procedure: (used if pectoralis muscle is removed or partially removed/damaged.)

Transverse rectus abdominis myocutaneous (TRAM) flap.

Rectus abdominus muscle is partially cut and brought up to the chest wall while other part is left attached to original muscle.

Alternate muscle is used to create a pouch for an implant or to form a new breast without an implant

ž2) Breast implant/tissue expansion procedure

Pectoralis muscle preserved.

If not enough muscle tissue - deflated pocket is placed & is filled /w injections of saline over time.

3) žNipple reconstruction

Grafting tissue from labia, abdomen or can tattoo areola.

Cannot restore lactation, nipple sensation & erectility.

15

What are some methods of radiation therapy in breast cancer?

1) Primary to prevent local breast recurrences after breast conservation surgery.

2)Adjuvant to prevent local and nodal recurrences after surgery.

3) Palliative for pain.

Lumpectomy is usually followed by radiation.

High dose brachytherapy – Allow high dose radiation to site for shorter time into tumor cavity after tumor removal.

16

What are the principles of chemotherapy in breast cancer?

žSystemic

Combination therapy preferred over single therapy

Doxorubicin (Adriamycin)

Nursing indications:

  • —Monitor for cardiotoxicity and heart failure. Careful cardiac assessment, listen for arrhythmias, look for fluid build up, listen for crackles.
  • —Refrain from immunizations until HCP approves.
  • —Avoid contact with any recently receiving any live virus vaccine.
17

What are the principles of hormonal therapy in breast cancer?

žTamoxifen ( Nolvadex ) is drug of choice in estrogen receptor + women with breast CA.

žAdjuvant after surgery & radiation.

žPreventive drug.

žSE:

  • Mild: Mood swings, HA, Vaginal dryness, Hot Flashes
  • Serious: Decreased visual acuity for high doses

žNursing Interventions: Monitor for DVT, PE, and stroke, SOB, leg cramps and weakness.

18

What are the principles of biologic and targeted therapy in breast cancer?

Biologic therapy:

Herceptin (Trastuzumab)

Used in clients with an overexpression of: Human Epidermal Growth Factor Receptor-2 (HER-2) protein.

Targeted therapy:

žBinds to HER -2 protein & kills breast cancer cells.

žCan be used with other chemo agents.

žSE/Nursing assessments:

  • Caution in women with preexisting heart disease.
  • Ventricular dysfunction & CHF can occur
  • Perform excellent assessments of cardiac functioning.
  • žNo hair loss
19

What are the risk factors, etiology, and clinical manifestations of cervical cancer?

žAvg age ~ 50 yrs.

žRisk factors:

  • Low socioeconomic status
  • Early sexual activity (<17y/o)
  • Multiple sex partners
  • HPV infection
  • Immunosuppression
  • Smoking

žEtiology & Patho:

  • Related to repeated injuries to cervix
  • HPV (types 16 & 18)

žClinical Manifestations:

  • Early changes
  • Usually asymptomatic but can lead to leukorrhea, and intramenstrual bleeding as disease progresses .
  • Late SX - Wt loss, anemia, cachexia (weakness and wasting of body tissue d/t chronic illness).
20

What are some diagnostic studies used for cervical cancer?

žDX studies:

Pap test

  • Abnormal pap smear requires F/U .
  • Minor Changes - repeat pap q 4-6 months x 2 yrs.
  • More prominent changes - colposcopy & biopsy.

Colposcopy: Exam /w microscope to ID epithelial abnormalities for biopsy.

Biopsy

  • Either punch or conization bx performed.
  • Conization can be both diagnosis & tx .

Cryotherapy: Freezing questionable tissue.

LEEP

  • Laser Cone Excision & Loop Electrosurgery Excision Procedure
  • Remove tissue & allow for histologic exam
  • If a woman has a LEEP procedure, she usually has more trouble with vaginal childbirth.
  • It’s where the surgeon takes an instrument to core out and remove cancerous lesions in the cervix. The tissue heals and scars, making the cervix less pliable and less compliant to childbirth processes.
21

What are the methods of prevention and treatment for invasive and noninvasive cervical cancer?

Prevention:

  • Gardisil/Cervarix cervical cancer vaccine
  • —Protects against HPV infection (types 16 & 18).
  • —Recommended beginning at age 11 for males and females.

Noninvasive disease:

  • Conization
  • Laser treatments
  • Cautery
  • Cryosurgery

Invasive Cancer of Cervix:

  • Surgery
  • Radiation
  • Chemo
22

What are the major risk factors and clinical manifestations of endometrial cancer?

žMost common gynecologic cancer, low mortality

Major risk factor is unopposed estrogen .

Others:

  • ^ age
  • Nulliparity
  • Late menopause
  • Obesity
  • Hypertension
  • Adipose tissue stores estrogen
  • DM
  • Smoking
  • Hereditary
  • Non-polyposis colorectal cancer

žClinical Manifestations:

  • 1st sign is abnormal uterine bleeding.
  • Pain is late sign.

žCollaborative Care: Endometrial biopsy is the preferred diagnostic procedure.

23

What are the treatment options for endometrial cancer?

Surgery

  • TAH & BSO with selective node BX.
  • This is followed by radiation.

Progesterone therapy

  • Megestrol (Megace)
  • —TX of choice when progesterone receptor status is positive & tumor is well differentiated.

Tamoxifen (Novaldex)

  • Alone or in combination /w progesterone.
  • Effective in advanced or recurrent endometrial cancer.

Chemo used when progesterone therapy not successful .

ž

24

What are the risk factors, clinical manifestations, and protective measures for ovarian cancer?

žMortality rate is high

Hard to detect until far advanced.

Caucasian women at greater risk.

Risk factors:

  • Family HX of ovarian CA
  • (1st degree relative with ovarian)
  • (family with + BR & colon CA )
  • Increased age
  • Nulliparity
  • High-fat diet
  • BRCA-1 gene
  • Early menarche/Late menopause
  • HRT
  • Use of infertility drugs

žClinical Manifestations:

  • Early- asymptomatic.
  • Later - ^ abdominal girth, bowel & bladder dysfunction, pain, menstrual irregularities, unexplained wt loss or gain.

Protective Benefits:

  • Breastfeeding
  • Multiple pregnancies
  • OCPs > 5 yrs use
25

How is ovarian cancer diagnosed? What are the treatment options?

žDiagnosis:

  • No screening test available
  • Yearly bimanual pelvic exam
  • Exploratory laparoscopy for DX when suspicious mass.
  • CA-125 cancer marker + ultrasound annually in women with risks.
  • OVA – 1 – Can detect if a pelvic mass is benign or malignant.

žTX:

TAH & BSO with omentectomy

Chemo

Radiation

Women @ high risk: Elective prophylactic oophorectomy + BCPs.

26

What are some surgical procedures for genital cancers?

žHysterectomy/Salpingectomy/Oophorectomy:

  • Removal of uterus &/or fallopian tubes & ovaries
  • Abdominal
  • Vaginal
  • Can be done laproscopically.

POST OP – (ABD DRSG (abd hysterectomy) or sterile perineal pad (vag. Hysterectomy).

27

What post-op complications should a nurse watch for and what physical restrictions should a nurse educate the patient about?

Observe for:

  • Bleeding - Moderate amt serosanguineous drainage OK.
  • Bladder atony: Accidental ligation of ureter could be cause. Check I & O
  • Abd distention – Paralytic ileus
  • Thrombophlebitis – Change position frequently. Use leg exercises & compression stockings.
  • Grief reaction
  • Estrogen deficiency (if oophorectomy) – HRT may be started initially
  • Post Vaginal Hysterectomy: Loss of vaginal sensation, temporary

Physical Restrictions:

  • No intercourse x 4-6 weeks
  • No heavy lifting x 2 months (10lbs)
  • Avoid activities that may ^ pelvic congestion
  • —Dancing
  • —Swift walking (moderate walking ok).
  • —Riding in auto for long periods of time.
  • Swimming may be helpful
28

What are two types of radiation therapy and what should a nurse know about each?

žExternal therapy

  • For external have pt. void prior to TX.
  • SE: enteritis & cystitis à natural reactions NOT overdose.

žBrachytherapy (internal therapy)

  • Delivers high dose of radiation directly to tumor.
  • Patient Prep: Cleansing enema, Indwelling catheter
  • OR/Procedure
  • Under anesthesia applicator inserted into endometrial cavity.
  • X-ray to assure correct placement.
  • Pt returns to room (needs to be lead lined room).
  • Applicator may cause uterine cramping requiring pain med.
  • Left in place 24-72 hrs with absolute bed rest.

Late complications of brachytherapy :

Fistulas

Cystitis

Phlebitis

Hemorrhage

Fibrosis

Nursing Interventions:

NO nurse in room with pt more than 30 minutes TOTAL /day.

Stay @ foot of bed or door to minimize exposure.

Visitors: —Advise 6 ft away & limit visits to < 3 hrs. NO PREGNANT VISITORS